1. Field of Invention
This invention generally relates to calculators for determining the financial liability of a patient for a medical service received by the patient.
2. Description of Related Art
Typically, for patients who are covered by a health insurance plan or who have healthcare benefits, some portion of the cost of a medical service received by the patient is paid by the health insurance plan, while some portion is paid by the patient. The patient's portion of the cost, also known as the patient's financial liability, often varies depending on a number of factors. These factors include, for example, the type of medical service provided, the nature of the medical service provider, and various parameters of the health insurance plan. The parameters of the health insurance plan can include the price of the medical service negotiated by the insurance plan with the provider, patient co-pay amounts, patient deductibles, and patient co-insurance. These variable factors and parameters make it difficult for a medical service provider to determine at the time of service the proper amount to collect from the patient for the service provided.
For example, for a minor out-patient procedure, the doctor's office performing the procedure would typically collect the patient's co-pay at the time of the service is provided. Although the patient may owe more than the co-pay amount due to the various parameters imposed by the patient's health insurance plan, the doctor's office would not typically collect more than the co-pay at the time of service. Rather, the doctor's office would send a claim to the patient's insurance company, which typically includes billing codes and any billed amounts. The patient's insurance company would then adjudicate the claim to determine the proper amount the insurance company is obligated to pay and pay only the proper amount to the doctor's office. The doctor's office would then bill the patient for any balance remaining to be paid.
As the cost of healthcare has increased and the design of benefits plans has shifted towards increased patient out-of pocket-payments, many medical service providers have attempted to collect a greater portion of the amount due from the patient at the time of service. However, because of the complicated nature of claims adjudication, it is often difficult or impossible for the medical service provider to estimate the proper amount to collect from the patient. For example, one factor that complicates the determination of the patient's financial liability for a given medical service is whether the patient has reached their total out-of-pocket maximum payment for the year in which the service is rendered. Because of these, and other difficulties, providers' success at collecting amounts other than co-pays from patients at the point of service has been limited. Providers incur significant costs to balance bill their patients; it is time consuming and often ineffective, resulting in significant accounts receivable write-offs.
In addition, in situations where the service provider cannot provide an accurate estimate of the patient's financial liability for a given medical procedure, the service provider is unable to tell the patient how much an elective procedure will cost the patient. Thus, the patient is unable to evaluate if he or she wishes to undertake the elective procedure. Similarly, without an accurate estimate of the patient's cost, the service provider is unable to negotiate with the patient regarding payment plan terms, which would allow the patient to make a fully informed decision about whether to proceed with the elective procedure.